AN APPLICATION OF 24MODEL TO ANALYSE CAPSIZING OF THE EASTERN STAR FERRY.

In the present study, the Eastern Star ferry accident was analyzed via 24Model. 24Model, as an accident causation model based on system thinking, holds that all causations of the accident are hazards and all hazards in the system need to be identified and comprehensively controlled in accident prevention. The result showed that five factors were the main causes of the accident. First, the direct causes: bad weather, the bad condition of the hull and the unsafe acts of the captain. Second, the indirect cause: the lack of safety awareness and safety knowledge of both the captain and the company's senior management. Third, there were loopholes in safety management system, including the training, supervision and execution of the company. Forth, the root cause: the company didn't establish a good safety culture. Last, the external causes: the severe market pressure, excessive regulatory authorities with puzzled relations and responsibilities--seriously hindered effective supervision. In order to prevent this kind of accident and to secure shipping system, the shipping companies and the relevant regulatory units should draw lessons from the five factors mentioned above, and take measures to identify and control those hazards. [ABSTRACT FROM AUTHOR]